Family Health Optima Insurance Plan

Unique Identification No.IRDA/NL-HLT/SHAI/P-H/V.II/129/14-15

Policy Schedule
Policy No.

: P/161112/01/2017/013683

Customer Code : AA0000900497

Customer Name : MR. ANSAR ALI SK
Proposer's Code : 2064017
Proposer's Name : MR. ANSAR ALI SK
Address
: A1/383, GAURHOMES
govindpuram

Previous Policy No.

P/161112/01/2016/011803

Issuing Office Code

161112

Issuing Office Name

Branch Office - Vaishali

Address

Phone No
E-mail id

:
:

Unit No.23,GRA Ground Floor,

Shipra Krishna Azure,
Near Kaushambi Metro
Station(Gate no.2)Near Wave
Cinemas,
Kaushambi, Ghaziabad,Uttar
Pradesh-201010
0120-4130156,4127426

Fulfiller Code

Ghaziabad,Ghaziabad,Uttar Pradesh201013

Phone No

: 9711524003//.

E-mail id

: .

: 30/11/2011
Proposal date
Date of Inception of first policy
Renewal Year

Fifth Year

Receipt No

1112014916

Receipt Date

15/12/2016

Premium

Intermediary Code

Service Tax : Rs 2025 /-

: Rs 13500 /-

Stamp Duty : Re 1 /-

30-NOV-11

Total Premium

Total Premium In Words

PERIOD OF INSURANCE
SCHEME - DESCRIPTION

: Rs 15525 /-

Name

Phone No

E-mail id

vaishali@starhealth.in
SH2327
:

BA0000102187

Ms.SHASHI THAKUR
/9810414577
aditya.veer20@yahoo.com

: Rupees Fifteen Thousand Five Hundred Twenty Five Only

FROM

: 16/12/2016 00:00:00

: 2 ADULTS + 2 CHILDREN

TO

Midnight Of 15/12/2017

BASIC FLOATER SUM INSURED : Rs. 500000

Five Lakhs Only
In Words:

Bonus : Rs 175000
.
Limit of coverage

: Rs. 675000

Recharge Benefit :

75000

Details of Insured Persons :

Sl.
No.

Name of the Insured

Sex

Date of Birth

AgeYrs/Mths

Relationship with
Proposer

ID Card No

Pre Existing Disease/s

MR. ANSAR ALI SK

15/11/1975

41 Yrs
1 Mths

SELF

2064017-1

No PED declared

SMT.ASFA BEGUM

02/04/1978

38 Yrs
8 Mths

SPOUSE

2064017-2

No PED declared

MD. WASIM

08/07/2007

9 Yrs 5
Mths

DEPENDANT
CHILD

2064017-3

No PED declared

LISA ALI

20/12/2008

7 Yrs
11 Mths

DEPENDANT
CHILD

2064017-4

No PED declared

Please check whether the details given by you about the insured persons in the proposal form are incorporated correctly in the policy
schedule. If you find any discrepancy, please inform us within 15 days from the date of receipt of the policy, failing which the details relating
to the insured person given in the policy schedule are deemed to have been accepted by you.
Warranted that in case of dishonor of premium cheque(s), the Company shall not be liable under the policy and the policy shall be void abinitio
(from inception).
Expenses relating to the hospitalisation will be considered in proportion to the room rent stated in the policy.

Entered By

: PREMIA

IRDAI Regn. No 129

This is an electronically generated

document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Corporate Identity Number U66010TN2005PLC056649

Email ID : info@starhealth.in

S GANESAN

CN=S GANESAN,
SERIALNUMBER=6334c2e11098300722dbd61428bc9cb25d
26f543b193f351fa3b4910df34f5b9, ST=Tamil Nadu, OID.
2.5.4.17=600034, OU="Management,CID - 4612742", OID.
2.5.4.20
=14b18504069ddb5554096364e0c4b387c06b26ac5c1bce4
0fb105bb79531ea07, O=STAR HEALTH AND ALLIED
INSURANCE COMPANY LIMITED, C=IN Date: 2016.12.15 9:
13:34 IST

1 of 3

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Attached to and forming part of Policy No. P/161112/01/2017/013683

THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED.
Important
In the event of hospitalization of insured person, intimation should be given to the Company immediately, however, within 24 hrs from the time
of admission.
Sector Classification
Urban

Toll Free No : 1800 425 2255

Email: support@starhealth.in, Fax No: 1800 425 5522.

Nominee Details:
Insured Name: MR. ANSAR ALI SK
Sr.
No

Nominee Name

Age

Percentage

Appointee
Name

Appointee
Age

Appointee
Relationship

Age

Percentage

Appointee
Name

Appointee
Age

Appointee
Relationship

Nominee Relationship

Age

Percentage

Appointee
Name

Appointee
Age

Appointee
Relationship

Nominee Relationship

Age

Percentage

Appointee
Name

Appointee
Age

Appointee
Relationship

Nominee Relationship

Insured Name: SMT.ASFA BEGUM

Sr.
No

Nominee Name

Nominee Relationship

Insured Name: MD. WASIM

Sr.
No

Nominee Name

Insured Name: LISA ALI

Sr.
No

Nominee Name

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Vaishali on 15th
Day of December 2016.

Entered By

: PREMIA

This is an electronically generated

document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10
2 of 3

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Hospitalisation Benefit Policy

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986
Policy No
Issue Office

P/161112/01/2017/013683

Type Of Policy : Family Health Optima Insurance-Revised

161112 - Branch Office - Vaishali

Address

Unit No.23,GRA Ground Floor, Shipra

Krishna Azure,
Near
Kaushambi
Metro
Station(Gate
no.2)Near Wave Cinemas,
Kaushambi,
Ghaziabad,Uttar
Pradesh201010

Toll Free No

0120-4130156,4127426

Email

vaishali@starhealth.in

This is to certify that MR. ANSAR ALI SK has paid Rs 15525 (Total Premium In Words
: Indian Rupees Fifteen Thousand
Five Hundred Twenty-Five Only ) towards Premium for Hospitalization Insurance vide Policy No: P/161112/01/2017/013683
for the Period 16-DEC-16 To 15-DEC-17 issued on 15-DEC-16 .
Payment received by Cheque/Credit/Debit Card vide collection No:1112014916 1112014916 15-DEC-16
Note :- This Certificate must be surrendred to the Insurance Company for issuance of fresh Certificate in case of Cancellation
of the Policy or any alteration in the Insurance affecting the Premium.

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Entered By

: PREMIA

This is an electronically generated

document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10
3 of 3

For Star Health and Allied Insurance Company Ltd.

Authorised Signatory